Only a handful of studies have investigated the nature, functional significance, and course of white matter abnormalities associated with mild traumatic brain injury (mTBI) during the semi-acute ...stage of injury. The present study used diffusion tensor imaging (DTI) to investigate white matter integrity and compared the accuracy of traditional anatomic scans, neuropsychological testing, and DTI for objectively classifying mTBI patients from controls.
Twenty-two patients with semi-acute mTBI (mean = 12 days postinjury), 21 matched healthy controls, and a larger sample (n = 32) of healthy controls were studied with an extensive imaging and clinical battery. A subset of participants was examined longitudinally 3-5 months after their initial visit.
mTBI patients did not differ from controls on clinical imaging scans or neuropsychological performance, although effect sizes were consistent with literature values. In contrast, mTBI patients demonstrated significantly greater fractional anisotropy as a result of reduced radial diffusivity in the corpus callosum and several left hemisphere tracts. DTI measures were more accurate than traditional clinical measures in classifying patients from controls. Longitudinal data provided preliminary evidence of partial normalization of DTI values in several white matter tracts.
Current findings of white matter abnormalities suggest that cytotoxic edema may be present during the semi-acute phase of mild traumatic brain injury (mTBI). Initial mechanical damage to axons disrupts ionic homeostasis and the ratio of intracellular and extracellular water, primarily affecting diffusion perpendicular to axons. Diffusion tensor imaging measurement may have utility for objectively classifying mTBI, and may serve as a potential biomarker of recovery.
Though recent behavioral work indicates that impairments in selective attention may be the most common and enduring cognitive deficit in mTBI (Mathias & Wheaton, 2007; Halterman et al., 2006), ...neuroimaging studies have yet to examine their neural correlates. ...this study proposed to investigate potential functional abnormalities in mTBI patients during performance of a multimodal selective attention task.
See related editorial, p 506
Study objective: Little is known about the accuracy and reliability of current triage methods. We examined agreement among observers with regard to the need for ED care ...and the ability to predict at triage the need for admission to the hospital and compared these findings with admission rates after medical evaluation and management.
Methods: We used a crossover design in which each subject was subjected to nurse or computer-guided triage first, the other type of triage second, and physician triage last. Our null hypothesis: Triage methods will yield the same results. Our patients were a consecutive sample of patients at the ED of a university-affiliated county referral center. Critically ill patients were excluded. Triage categorization was examined for interobserver agreement (κ-statistic) and prediction of admission (sensitivity, specificity, and predictive values).
Results: Of the 5,106 patients enrolled in the study, 289 (6.2%) were admitted. With regard to the agreement of triage categorizations, we found κ-values of .452 and .185, respectively, for physician triage compared with nurse (SE±.012) and computer triage (SE±.012) (
P=.001 for the difference between the κ-values). Sensitivity and specificity in predicting admission were 41.3 and 93.8, respectively, for nurses; 61.6 and 87.1, respectively, for physicians; and 68.2 and 73.6, respectively, for computer-aided triage.
Conclusion: We found great variability among physicians, nurses, and a computer program with regard to triage decisions. Comparison of the three groups' triage decisions with actual data after medical evaluation and management showed that none of the three performed well in predicting which patients required admission. Until triage methods are standardized and validated, triage decisions should not be used to determine the timeliness of access to emergency care. Brillman JC, Doezema D, Tandberg D, Sklar DP, Davis KD, Simms S, Skipper BJ: Triage: Limitations in predicting need for emergent care and hospital admission.
Ann Emerg Med April 1996;27:493-500.
See related editorial, Triage and Emergency Department Services
The authors propose a three‐year curriculum for emergency medicine residents using human simulation both to teach and to assess the Accreditation Council for Graduate Medical Education (ACGME) core ...competencies. Human simulation refers to a variety of technologies that allow residents to work through realistic patient problems so as to allow them to make mistakes, learn, and be evaluated without exposing a real patient to risk. This curriculum incorporates 15 simulated patient encounters with gradually increasing difficulty, complexity, and realism into a three‐year emergency medicine residency. The core competencies are incorporated into each case, focusing on the areas of patient care, interpersonal skills and communication, professionalism, and practice based learning and improvement. Because of the limitations of current assessment tools, the demonstration of resident competence is used only for formative evaluations. Limitations of this proposal and difficulties in implementation are discussed, along with a description of the organization and initiation of the simulation program.
Study objective: A modification of the standard Department of Transportation student paramedic curriculum encouraging individualized patient assessment decreases inappropriate on-scene procedures ...(OSPs) and scene time, measured on simulated patients.
Methods: Scenario-based testing from 1991 through 1993 was videotaped for all students. A new trauma curriculum was introduced in 1992, individualizing patient assessment and prioritization of OSPs. Recorded OSPs included spinal immobilization, application of military antishock trousers, endotracheal intubation, cricothyrotomy, intravenous catheter insertion, and needle thoracostomy. Twenty videotaped random student performances of the 1991 class was compared with a similar sample of 20 from the 1993 class; scene times and the OSP numbers were measured. Two board-certified independent emergency physicians unfamiliar with the students or the new curriculum reviewed all 40 tests on a master videotape. Patient assessment appropriateness, scene time, OSPs, scenario difficulty, and number of inappropriate OSPs were evaluated using a linear analog scale. Data are presented as means with confidence intervals (CIs), analyzed by Student’s
t test and the Mann-Whitney 2-sample test.
Results: Scene time from 1991 to 1993 decreased overall with a mean of 4.3 minutes (95% CI 2.8 to 5.8 minutes), as did the number of OSPs: 3.1 versus 1.7 (mean difference, 1.45 OSPs per scenario; 95% CI .91 to 1.99). Physician reviewers noted improvements in the appropriateness of patient assessment, scene time, and OSPs from 1991 to 1993. There was no significant difference in scenario difficulty for 1991 compared with 1993. Inappropriate OSPs done on scene declined. Physician 1 indicated a mean of inappropriate procedures of 1.6 in 1991 versus .5 in 1993. Physician 2 indicated a mean of 1.4 in 1991 versus .3 in 1993.
Conclusion: This new paramedic curriculum decreased on-scene time and inappropriate use of procedures in stabilizing the condition of patients with simulated critical trauma.
Johnson DR, Macias D, Dunlap A, Hauswald M, Doezema D: A new approach to teaching prehospital trauma care to paramedic students.
Ann Emerg Med January 1998;33:51-55.
The Accreditation Council for Graduate Medical Education (ACGME)-identified core competency of systems-based practice requires the demonstration of an awareness of the larger context and system of ...health care, and the ability to call on system resources to provide optimum care. This article describes an approach to teaching and fulfilling the requirement of this core competency in an emergency medicine residency. Beginning residents are oriented to community resources that are important to the larger context of care outside the emergency department. Each resident completes a community project during his or her residency. Readings and discussions concerning community-oriented medical care and the literature of research and injury prevention in emergency medicine precede the project development. Several projects are described in detail. Such projects help to teach not only awareness of the community resources of the greater context of medical practice outside the emergency department, but also how to use those resources. Projects could be a main component of a resident portfolio. This approach to teaching the core competency of systems-based practice is proposed as an innovative and substantial contribution toward satisfying the requirement of the core competency.
Both professionalism and interpersonal communication are core competencies for emergency medicine residents as well as residents from other specialties. The authors describe a weekly, small‐group ...seminar lasting one year for emergency medicine residents that incorporates didactic materials, case studies, narrative expression (stories and poems), and small‐group discussion. Examples of cases and narrative expressions are provided and a rationale for utilizing the format is explained. A theoretical model for evaluation measures is also included.
ABSTRACT
There is a rapidly growing interest in emergency medicine (EM) and emergency out‐of‐hospital care throughout the world. In most countries, the specialty of EM is either nonexistent or in an ...early stage of development. Many countries have recognized the need for, and value of, establishing a quality emergency health care system and are striving to create the specialty. These systems do not have to be high tech and expense but can focus on providing appropriate emergency training to physicians and other health care workers. Rather than repeatedly “reinventing the wheel” with the start of each new emergency care system, the preexisting knowledge base of EM can be shared with these countries. Since the United States has an advanced emergency health care system and the longest history of recognizing EM as a distinct medical specialty, lessons learned in the United States may benefit other countries. In order to provide appropriate advice to countries in the early phase of emergency health care development, careful assessment of national resources, governmental structure, population demographics, culture, and health care needs is necessary. This paper lists specific recommendations for EM organizations and physicians seeking to assist the development of the specialty of EM internationally.
To examine the effect that cerumen occlusion of the ear canal has on infrared tympanic membrane temperature measurement.
A prospective, randomized, single-blind human study was carried out in a ...university hospital observation unit. The subjects were a convenience sample of human volunteers ages 18 years or older who did not have cerumen occlusion or scarred tympanic membranes. A paraffin-coated human cerumen plug was placed in one randomly chosen ear, and after 20 minutes of equilibration the temperature of each ear was measured with an infrared thermometer. Analysis of the difference in mean temperature between the occluded and nonoccluded ears was by Student's paired t-test.
Infrared tympanic membrane temperatures were measured in 43 subjects aged 21 to 58 years. The mean temperature of the occluded ear canal was 0.3 degrees C lower than that of the opposite ear canal (p = 0.0001, 95% CI 0.16-0.45 degrees C).
Cerumen occlusion of the ear canal causes underestimation of body temperature measure by infrared tympanic membrane thermometry.
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